Impact of the introduction of a combined Haemophilus B conjugate vaccine and hepatitis B recombinant vaccine on vaccine coverage rats in a large West Coast health maintenance organization

We evaluated the effect of introduction of a combined hepatitis B-Haemophilus influenzae b vaccine on vaccine coverage rates in a large health maintenance organization and found a modest improvement in up-to-date immunization status.

Psychotropic medication use in a population of children who have attention-deficit/hyperactivity disorder

OBJECTIVE

Recent reports suggest a trend of increasing prevalence of psychotropic drug prescriptions among children with attention-deficit/hyperactivity disorder (ADHD); however, reasons for the increased use of such medications is unclear. The objectives of this study were to examine differences in nonstimulant psychotropic medication fills between children with and without identified ADHD and to assess associations with non-ADHD neurobehavioral disorders.

METHODS

A population-based retrospective matched cohort study was conducted of a large group model health maintenance organization located in western Washington State. Eligible patients were children who were ages 3 to 17 years and were continuously enrolled and used services from January 1 to December 31, 1997 (N = 57 216). Children with ADHD were identified by a diagnosis of ADHD or a pharmacy fill for a stimulant medication using automated patient files. Children without ADHD were randomly selected and matched 4:1 to children with ADHD on age and gender. Neurobehavioral disorders and pharmacy fills for psychotropic medications were measured.

RESULTS

During 1997, 2992 children were identified as having ADHD (5.2%). These children were more likely to have a diagnosis of a non-ADHD neurobehavioral disorders (adjusted odds ratio: 6.3; 95% confidence interval: 5.4-7.3) than children without ADHD. Although most (78%) were treated with stimulant medications, children who were identified as having ADHD were also more likely to receive pharmacy fills for nonstimulant medications than were children without ADHD. Nonstimulant medications were more often used along with stimulant medications and were frequently prescribed in association with ADHD after controlling for other disorders.

CONCLUSIONS

Children who were identified as having ADHD were more likely to have a diagnosis of other neurobehavioral disorders and to receive nonstimulant psychotropic medications than were children without ADHD. Because many of these drugs have little or no empirical basis in the treatment of ADHD, the rationale for their use is less clear. Future research to examine the use, effectiveness, and safety of these medications alone and in combination in children with ADHD is urgently needed.

Successful community-based laboratory services program for long-term care facilities, Part 2

Hagerstown Medical Laboratory, Inc., located in Hagerstown, Maryland, has an outreach program that currently provides laboratory services to 52 long-term care facilities. Part 1 of this series, published in the May/June 2001 issue of Clinical Leadership & Management Review, discussed general organization, staffing, and safety issues for their Nursing Home Program. Part 2 relates their experience with contracts, fees, and reimbursement.

Utilization and cost of health care services for children with attention-deficit/hyperactivity disorder

BACKGROUND

Despite an increasing prevalence of diagnosed attention-deficit/hyperactivity disorder (ADHD) among children, the impact of ADHD on utilization and costs of health care services is largely unknown.

OBJECTIVE

To examine differences in health care utilization and costs between children with and without ADHD.

DESIGN

Retrospective matched cohort study conducted from January 1 to December 31, 1997. Setting. Health maintenance organization in western Washington State.

PARTICIPANTS

Children aged 3 through 17 years who were continuously enrolled in the health maintenance organization and used services during 1997 were eligible. Children were identified with ADHD if they had a diagnosis of ADHD or a prescription for a stimulant medication using automated patient files. Children without ADHD were randomly selected as controls and matched 4:1 to children with ADHD on age and sex.

OUTCOME MEASURE

Utilization and costs of specific categories of health care services. Results. A total of 2992 children (5.2%) were identified with ADHD. Children with ADHD incurred significantly greater per capita total costs ($1465 vs $690) than children without ADHD. Children with ADHD had 9.9 times more outpatient mental health visits (1.35/year vs 0.14/year), 3.4 times more pharmacy fills (11.25/year vs 3.30/year), and 1.6 times more primary care visits (3.84/year vs 2.36/year) than children without ADHD. The adjusted incremental costs were estimated to be $375 (95% confidence interval: $336-$416) for children with ADHD alone and $812 (95% confidence interval: $671-$973) for children with ADHD plus coexisting mental health disorders.

CONCLUSIONS

Children with ADHD use significantly more health care resources and incur significantly higher costs than children without ADHD. Coexisting mental health disorders substantially increase the cost of treating ADHD. Resource allocation decisions should consider the contributions of primary care, outpatient mental health, and pharmacy costs to the overall costs of care for children with ADHD.

Successful community-based laboratory services program for long-term care facilities, Part 1

Hagerstown Medical Laboratory, Inc. (HML) is a regional reference laboratory in Hagerstown, Maryland, that provides laboratory services to more than 50 long-term care facilities (LTCFs, or nursing homes) in Western Maryland and West Virginia. HML also operates the rapid response laboratory at Washington County Hospital and performs house calls for homebound or bedridden patients through its Nursing Home Program (NHP). This article relates HML's successful experience with an outreach program that provides laboratory services to LTCFs.

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children

CONTEXT

The benefits of continuity of pediatric care remain controversial.

OBJECTIVE

To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization.

DESIGN

Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider.

MAIN OUTCOME MEASURES

ED utilization and hospitalization.

RESULTS

Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma.

CONCLUSIONS

Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.